Low Back PainStructural Yoga Therapy Training

June 2008 New York City

Annabelle Berriosmiamiyogatherapy@gmail.com

305-790-9599

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I. CASE STUDY

A. Initial Intake May 4, 2008

Jeanne is 52 years old. She is single, and lives with her 2 dogs walking distance from the beach and parks. Her speech is slow, articulate and direct. In her youth, she participated in ballet and acrobatics. She teaches language arts to seventh graders at a public school for high risk youth. She had 2 car accidents in 1989 within a month and a half of each other. The first one was a rear collision which caused whiplash and forced her knees unto the steering wheel. The second accident was a side impact, but not as strong as the first. She had physical therapy and was told by doctors that she would have to exercise “as if I were 10 years older”.She reports feeling a muscular ache in her lower back (right above the pelvic crest) since the accidents. She likens it to the feeling of a bruise, in that it hurts more when she touches it, and when she doesn’t touch it it’s more of a “general discomfort”, a pain level 4 or 5 on a scale of 10. PMS, lifting heavy objects, crunches or push ups, soft mattresses and sitting for prolonged periods aggravate it. In those cases, the ache feels more like throbbing, and 2 Advil usually relieve it. The pain level is 7-8 when exacerbated, which she says does not happen often. She says she does not perceive any restriction in movement.

She also experiences stiffness in the front of the knees. She just became aware of this in the past month, because she was recently on her knees cleaning as part of a move, also lifting heavy objects. Before, she says only experienced creakiness in the knees. Her knees only bother her when there is compression, as when they are flat against the floor, so she uses a cushion with two scooped areas for the knees which relieve any discomfort. Her discomfort level is 3.

She also experiences difficulties in breathing because of congestion.

In spite of the above, and of bruising easily, she indicates she has a high tolerance for pain (has had “discomfort for most of [my] adult life”) and does “not use pain as an excuse or a limitation”. She used to practice yoga until 2 years ago (“even backbends and headstand”) but gave it up in favor of other priorities, such as caring for her sick mother, school, teaching and preparing for the GRE. At work, she stands all day and at home she is sedentary. She attributes her pain/discomfort to lack of exercise. Her SYT objective is to regain her agility because “I feel better mentally when I exercise”, explaining that her need for mental comfort exceeds the need for physical comfort. She sabotages her best intentions for exercise by focusing on the needs of others over her own, which she has viewed in the past as more important priorities. She feels uplifted by her dogs and reading.

She committed to a practice of up to 20 minutes a day for now until school ends. She plans to practice in the evenings, as she is “not a morning person,” prefers to sleep 8 hours when possible. Sleeps heavy, hard to get up. Our rapport is direct yet easy going, joking at times.

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B. Physical Assessment Posture Body reading: - May 4, 2008:- Height: 5’8; weight: 158 lbs; BMI: 24 (standard). - Large bone structure, proportional to height- Carrying angle 10 degrees both arms - Slight forward neck, also neck leans slightly to the right- Hyper-extended elbows, 7 degrees both sides

- May 25, 2008:- Foot turn out, especially right side - Unstable s/i (left side moves down, right side moves up)- after s/i stabilization

exercise,stabilized.- June 1, 2008:

- No lumbar curve- Scoliometer: moves 5 degrees to right in thoracic region, long C curve (left thoracic curve).

Apex: T7 to approximately T12. - Observed lesser and more even foot turnout.- S/i stable

- June 8, 2008:- S/i unstable (left side rises, right not moving).- Prone position: space between ribcage and hips looks longer on left side. -July 29, 2008:-S/i stable

Muscle Testing Assessments

Joint Action May 4,2008

May 4,2008

June 1,2008

June 1,2008

July 29,2008

July 29,2008

Left, 1-5

Right, 1-5 Left, 1-5

Right, 1-5

Left, 1-5

Right, 1-5

KNEE Extension 4 4 4 4 4 4Flexion 2.5 3 3.5 3 3.5 3HIP Hip Flexors & Abs (Supine) 3 2 3

Trunk Flexion (Supine)

2 (upper weak - couldn’t get up)

3 (lower weaker, legs lifted slightly after sat up)

4 (came up easily but feeling the pain in the lower back)

Hip Flexors - Bent Knee (Supine) 2.5 2 3 3 3 4Iliopsoas Isolation (Supine) 3 3 4 4 4 3.5

Sartorius Isolation (Supine)

4 (feels cramp in hamstring)

3 (feels cramp in hamstring)

3.5 (cramping)

3.5 (cramping) 3.5 3

Abduction (Side Lying) 4 4 4 4 4 4Adduction (Side Lying) 2 2.5 3.5 3.5 3.5 4Gluteus Maximus Isolation (Prone) 4

4 (knee lifts higher) 4

4 (knee lifts higher) 4 4

External Rotation (Prone) 4 4 4 4 4 3Internal Rotation (Prone) 2 3 3 3.5 3 3.5Hip Extensors(Prone) 2.5 2.5 3.5 3.5 3.5 3

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Range of Motion Assessments

Joint Action ROMMay

10,2008May

10,2008June

8,2008June

8,2008August 8,2008

August 8,2008

Norm° Left Right Left Right Left Right

KNEE Extension 0°/180° 0 0 0 0 0 0Flexion (Supine) 150° 145 145 145 145 140 140HIP Flexion (Bent Knee) 135° 130 125 110 120 120 120Flexion (Straight-Leg Raise) 90° 95 95 80 90 90 90Flexors-quad/psoas restriction NSS stdrd stdrd External Rotation (Supine) 45°-60° 40 45 30 40 30 30Internal Rotation (Supine) 35° 30 25 25 25 22 15External Rotation (Prone) 45°-60° 50 55 75 75 40 35Internal Rotation (Prone) 35° 45 35 40 40 45 40Adduction (Side Lying) 30°-40° 45 40 50 50 50 50Abduction (Side Lying) 45° 50 50 40 40 30 30

C. Summary of findings:CI.5/4/08 (unless otherwise noted):

Strengthen Stretch Release

hamstrings hamstrings gracilis (5/25/08)

hip internal rotators psoas hip flexors (5/25/08)

adductors IT band (5/25/08)

rectus abdominis quadraceps (6/8/08)

rectus femoris (hip flexors)

saritorius (6/1/08)

D. Recommendations after first session, May 4, 2008:

- 1st half of the Joint Freeing Series (JFS), 6 repetitions per movement, breathing naturally. She has a hard time coordinating the breath to the movement so for now she will focus on awareness of feeling during movement. Perform the movements slowly, relaxing the effort, as she has a tendency to want to overpower the joint through strong willpower.

- Do not push through pain; instead, back off movement if feel pain. Discussed the difference between pain and naturally occurring currents of sensation.

- 5 minute savasana after JFS, beginning with breath awareness (abdominal breathing), then letting go of breath.

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E. Results of recommendations: second session, May 11, 2008:

-Jeanne skipped her homework only one day. She did miss an additional day (Friday) but made up the time by doing the series twice on Saturday (morning and afternoon). -Only did Savasana one day, says she forgot it was written at the bottom of her homework page.-Feels less morning stiffness. She feels “looser from her lower back down”, and has less discomfort. No soreness after doing JFS. These are signs of increased sattwa.-Shows more attention to feeling in her body, by asking to review some movements to ensure she is feeling it in the right place, and more responsive about this also (svadyaya). In this regard, her vata appears less unbalanced. -Thinks series is boring, “really boring”. Still recognizes the value of building strength, and recalls how a vigorous yoga practice led to discomfort or pain in the past, although being so vigorous made it easier to let go at the end in savasana. She seems attached to the way she did it before. -She has been using cushioning on knees and resting in child’s pose between exercises when feels her wrists need a break. This appears to be an example of breaking a pattern of pushing through pain because she is “strong”. On the other hand, she decided to work on coordinating the breath to the movement, eager to “get it right” (when to inhale and exhale) rather than finding comfort and release.-Knows she is not overweight but wants to be skinny, because has a large frame thinks looks better that way. Wants to be as slim as she used to be when she was younger.

D. Recommendations after second session, May 11, 2008: - We reviewed certain poses she had questions about until she was confident.- Added a modification to cat, emphasizing abdominal contraction, to work on strengthening

rectus abdominis.- Tried lifting one leg at a time in internal rotation from dandasana - she immediately felt

cramping so we backed off. Will wait until next session to suggest another variation to strengthen hip internal rotators, one that isolates those muscles only.

- Start savasana by practicing the wave breath - we discussed the different directions of the breath in inhalation and exhalation.

- Agreed not to add 2nd half of JFS yet because still takes her 20 minutes to get through 1st half.

E. Results of recommendations: third session, May 21, 2008: (phone check-in, as I was in New York on our usual meeting day)

- The week following our last session she followed the program 4 out of 7 days. This week (up to 5/21) she had skipped 2 days already . Not doing savasana.

- -Jeanne is worried about budget cuts by the Board of Education. She decided to postpone taking the GRE to take some pressure off, free up her time to visit family and prepare a better portfolio for her admissions application.

- Lower back bothering again, which she deemed noteworthy only because she had felt relief before. The discomfort is no more than the low level discomfort experienced before starting this program, and it is irregular. Last week worked unusually long days with only a 45 minute break to get food, eat and prepare for the next class. She points out last week was carrying a heavy bag predominantly on one shoulder (right), where “one book alone weighs 10 pounds”. She recognizes these are triggers to her back pain (tamasic pitta). This week her schedule is lighter, with a longer break between classes, has not carried bag and feels “pain not as bad”.

- Dogs are very distracting to her when she is practicing on the floor - they jump on her, lick her face.

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D. Recommendations after third session, May 21, 2008: (by telephone)- She agreed to have the dogs out of the room doing practice to minimize distractions.- Savasana-partial explanation of its importance- Savasana - polish: reviewed with her by phone and then e-mailed: Once comfortable (free of

physical tension), keep body completely still. Form an intention to stay attentive and alert throughout the process. Make an affirmation to clarify your goal (repeat to yourself "I am relaxing"). Focus on breath: 4 part breath: inhale for 4 seconds, pause 1 second, exhale 4 seconds, pause 1 second (5 minutes). If any distractions arise, acknowledge them then return your attention to the breath. Remind yourself of your goal. After 10 rounds of 4 part breath, let go of the breath, let your body be heavy. Remind yourself that you are relaxing. Continue for approx. 2 minutes. Stretch your body and slowly come to sit, letting the head be heavy and last to come up. No sudden or quick movements.

- Pointed out lifestyle factors that aggravate condition.

E. Results of recommendations: fourth session, May 25, 2008 -Cleared out 2nd floor room upstairs, where she is now practicing final relaxation (savasana). That is working well as it is quiet and the dogs do not come into that room (she closes the door). -In total, did practice 4 times a week (including today, she did her practice this morning, including savasana). -Gets frequent sinus infections, thought she was developing one earlier in the week, that is why she skipped some days of practice.-No pain today in lower back today.-Has been doing lesson plans at school this week to eliminate need to carry heavy bag. She used to have a suitcase with wheels to transport her heavy books to school, but the wheels broke before it was a year old, so “I became “stubborn” about not getting another.

D. Recommendations after fourth session, May 25, 2008- Neti pot every day (for discharge of excess mucus build up). Showed her device and how to use it.- Reminded Jeanne that the focus JFS is look for feeling of release, not pushing.- Preparatory exercise before s/i stabilization (to warm up hip joint): lying face up, feet apart on

the floor, knees bent, moving down one knee at the time in direction of foot.- S/i stabilization variation: “windshield wiper” (lying face down, knees apart, feet up, moving one

foot at a time in the direction of opposite knee).- regular s/i stabilization exercise- JFS variation: knee flexion and extension with no hands - to strengthen hamstrings. - JFS substitution: instead of cat/cow, boat pose: hands under thighs, knees bent, feet lifted,

dynamic: hip flexion and extension - to strengthen rectus abdominis . Jeanne likes this a lot.- JFS variation: sunbird: knee above hip, knee flexion and extension - to strengthen hamstrings. - Part 2 of JFS (upper body) (optional) 6 repetitions per movement - she is concerned about

time but may try to do one part in the morning and one part in the afternoon every other day, because feels more release doing entire series which helps her relax in savasana.

- Jeanne feels frustrated about teaching unreceptive and disruptive (sometimes even violent) students. She is also angry about lack of support by the administration due to politics. She wants to help, but “in my terms”, meaning she feels the need to be respected as an authority figure as a pre-requisite for success; she says: “I have a strong belief in fairness”. Jeanne has a hard time going along when she feels this condition has not been met. “I want to help my way”.

- Savasana 4 part breath- we discussed in detail the benefits of Savasana so she understands its importance, and practiced a 7 minute relaxation with instrumental music in the background. I felt her relax for the first time. “That was better”, she said, “I could let go more with the music and without distractions.” She plans to use soft instrumental music at home as a tool to aid relaxation and block out outside noise during savasana.

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- Pointed out lifestyle factors that aggravate condition.

E. Results of recommendations: fifth session, June 1, 2008:-Did practice 5 times this last week, in the mornings on weekdays (she has incorporated the practice into her morning routine). She did lower body work and regular s/i stabilization exercise, no upper body JFS. She has not acquired a neti pot. Jeanne has noticed a greater awareness of her body, in terms of what muscles she is using when moving in a particular way (ie., walking). This shows a her vata is moving in the direction of balance. She also noticed she is “moving more easily” when walking.-However, even though her weakest muscles appear to be strengthening (see Muscle Testing table) she insists on engaging in activities which trigger/aggravate her back pain (such as moving furniture, or remaining in a squatting position way past her comfort level). This makes it difficult to assess whether, and to what extent, yoga therapy can alleviate her back pain. Jeanne doesn’t like referring to her back discomfort as pain she defines pain only as a sensation that distracts attention from everything else. Instead, she categorizes it as “a general awareness of the area,” a tightness, soreness likened to medium pressure on a bruise. It usually manifests the next day after a strenuous activity.-Jeanne likes moving furniture, says she likes change (vata). Most recently, though, it was due to the need to remove rugs, and also as part of her recent move. She believed she was being mindful when moving a heavy table that usually requires 2 people to move it by sitting down and pushing it with her feet. She likes order and she wants to be comfortable in her house (which she is not if things are not in place). Her tendency is to keep going until she finishes, even if it means skipping meals or pushing through discomfort. This aggravates her vata.-During the muscle tests, Jeanne was able to discern which muscles felt stronger or weaker. She was happy to remember she had been unable to sit up in trunk flexion. However, she felt the lower back soreness as she sat up.

D. Recommendations after fifth session, June 1, 2008:-Since her s/i test was standard this time, will not do regular stabilization exercise, but will do the “windshield wiper” variation, to counteract imbalances in vata manifesting in this area.-Took out JFS 1-3 (pertaining to ankles) so she could spend her available time focusing on her weakest areas.-JFS #5 variation (internal and external rotation): 10 repetitions instead of 6. -JFS #6 variation on the cat /cow: knees apart, feet together, lift knee - 6 repetitions - to strengthen gluteus medius and stretch .-Rolling bridge - to strengthen hamstrings and gluteus and stretch psoas.-Abdominal twist to strengthen rectus abdominis, adductors, middle and lower trapezius and stretch gluteus medius and TFL.-Boat variation: after we reviewed boat, changed to feet on floor, since with her feet up she felt more discomfort in her back.

E. Results of recommendations: sixth session, June 8, 2008:-Practiced 4 times this week.-Jeanne says her low back pain remains the same. This week she has not been moving furniture or heavy objects. She voices concern that both her sources of income (job and rental income) could be in jeopardy. -She feels soreness above her low back pain (thoracic region) and down the front of her legs (pointing to belly of rectus femoris), likens it to soreness felt when starting to exercising muscles after stopping for a long time. She differentiates these sensations from her low back pain in that she feels weakness in her low back, not in the other areas. She reports feeling more soreness the days she skipped doing the practice. -She has been practicing savasana - says not sure “doing it right” because she would be “well focused” on her breath and “dissolve into nothingness” for 20-30 seconds” before noticing

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thoughts again (ie., why is the dog barking and the many thoughts evolving from that one) and reminding herself to get back to the breath. I congratulated her on her progress. She is beginning to understand the importance of practicing savasana to create a safe space to temporarily release/relieve her mind from the usual tasks of worrying, planning, re-playing stressful memories. She likened it to her love of reading, for in reading, she escapes her habitual thoughts. D. Recommendations after sixth session, June 8, 2008:-Add regular s/i exercise to “windshield wiper” since s/i unstable.-Tried psoas/saritorius isolation but immediately she said she felt a cramp coming on, so we let it go. This also happens during the saritorius muscle test.-She will add to the routine Upward Stretched Legs pose (dynamic) to strengthen her hip flexors, rectus abdominis and stretch her hamstrings.-Changed savasana routine (had her experience during session first). This was the first time I felt Jeanne really let go. “I am very relaxed,” she said after. No pain during savasana, no pain after savasana, when sitting. She also said this way felt more natural to her, easier to get into it.Procedure: After setting up music, getting comfortable, aligning body: 1. Selective relaxation (my feet are relaxing, my legs, etc all the way to head).2. Once comfortable (free of physical tension), keep body completely still.3. Focus on breath: "wave breath" (meaning, feel breath moving downwards, filling with air chest to abdomen)4. Slow down breath5. Ask your thoughts to slow down.6. Place your hands in yoni mudra (means "sacred seal") on your abdomen (make a downward pointing triangle with hands, navel is inside middle of triangle)7. Inhale into any part of your body where you feel sensation (including pain). Exhale send sensations to triangle (if pain, visualize pain getting smaller and smaller until disappears).8. When you feel sensations inside the triangle, slide hands down to lower abdomen (under navel) and stay for 2 breaths.9. Let go of breath, lie heavy

E. Results of recommendations: seventh session, June 16, 2008:-Practiced only 3 times since I last saw her, the days following the end of the school year. She had pressure headaches every day the last week of work, and she worked long hours without stopping to rest, bent over a desk grading to get everything done in time for the end of the school year. -She notices feeling additional stiffness/discomfort when she does not exercise. The muscular soreness she referred to on her last visit is no longer present.-She notices increased ROM in knee flexion.-She just learned some of her students performed very well in standardized exams and will be moving into more advanced class levels. She wants this to translate to a better work assignment for the coming school year (teach 8th grade).-She has not carried the heavy book bag since the last time she mentioned it. -She felt her low back pain/stiffness when we started today’s practice (“the usual stiffness, I don’t call it pain,” she says), but not feel it afterwards. Said she felt great and looked very relaxed, “but I did take ibuprophen earlier today,” she added later.

D. Recommendations after seventh session, June 16, 2008:-Reviewed s/i stabilization exercise, will keep that and no longer do windshield wiper since now fully comfortable doing other variation. 6 repetitions. -Increased repetitions of JFS to 10Added: Dandasana - dynamic - to strengthen hip flexors.

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Kept -JFS 4 without arms (strengthen knee flexors and extensors), JFS 5 (strengthen internal/external hip rotators), JFS 7 with foot turn out (strengthen hip flexors and extensors).-Asanas: 6 repetitions, all dynamic:Added: adho mukha svanasana (strengthen hip flexors)Kept: rolling setubandhasana (strengthen gluteus and hamstings)Kept: urdhva prasarita padasana (strengthen hip flexors)Kept: jatahara parivartanasana (strengthen abductors and obliques, stretch gluteus medius)Added: apanasana (strengthen hip flexors)Kept: paripurna navasana (feet on floor) strengthen rectus abdominis and hip flexors)Kept: savasana (same) Added: mental repetition (at end): “I am abundance”. Conversed about the power of positive affirmations. Added: baddha konasana strengthen psoas, saritorius and gluteus medius. -Emphasize hip flexors when walking.-Yoni mudra for headaches.

E. Results of recommendations: eighth session, June 23, 2008:-Practiced 5 times this past week, takes her about 30 minutes. Finds it challenging to fit in time for the practice because even though she is not working, still has a big list of errands and activities she wants to fit in. However, she states she can continue to do it for now. -Her back feels the same, low grade discomfort that comes and goes. Feels soreness in her hip flexors that becomes noticeable when she is sedentary (lying on the couch, in bed) and dissipates with movement. She takes Advil to relieve the discomfort.-She does not notice an additional release or relaxation in savasana, says that by that time already feeling relaxed. We spoke about expectations about what savasana is supposed to achieve. She expressed an expectation that she “should” be in a thought free state. She also thought that, because I always ask her about her savasana practice, that I had an expectation about what I thought she was supposed to achieve. We discussed letting go of expectations, letting it be whatever it was, with the object of merely slowing down the breath to slow down thoughts and cultivate awareness and release. -On her own Jeanne decided to bring back the windshield wiper exercise, because it warms up her body to the regular s/i exercise. I took this as more signs of increasing body awareness. -She finds it hard to get up in the morning, which surprises her because she thought than now that she is not having a glass of wine to relax she thought she would sleep better. I take this to mean that she is experiencing a loss of energy.

D. Recommendations after eighth session, June 23, 2008:- Yoni mudra practice for pain management and help her fall asleep. -Her awareness of her stress level is inconsistent: she first said school stress was slowly waning, as it slowly sinks in she is on vacation (describing a recent dream abut school). Later she said she doesn’t need relaxation because she has no stress on vacation. However, towards the end she mentioned her stress at her dog’s incessant barking in response to thunderstorms (which we’ve had often). Her lack of clarity points to vata imbalance. I think she could benefit from more pranayama but for now stick to the wave breath as she is not receptive to doing more. I explained the interrelation between the speed of the breath and the speed of the thoughts, since Jeanne wants to understand the rationale behind the practices before doing them. -She is planning to start going on walks for the purpose of exercise while she is visiting her mother in Delaware next month. She was struggling with the instruction to emphasize hip flexors during walks, as this feels unnatural to her. We discussed other alternatives to achieve the same goal. She suggested doing standing knee lifts at home, which she felt engaged her hip flexors, or dynamic lunges with the back knee off the floor (since feels discomfort with her knees pressing down on the floor). However, she felt an uncomfortable tightness on the hip that was stretching, so she chose doing the standing leg lifts. As for the walks, she stated she could start slow and gradually increase the pace and duration, and could re-assess her strategy

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whenever she first became aware of pain. She admitted that she struggles with balance, meaning Patanjali’s concept of “steady and comfortable” exercise, having long ascribed to the rajasic slogan of “no pain, no gain. However, when I asked to ponder whether pushing herself past pain had actually ever produced a gain, she was attentive and receptive. This exchange demonstrated how Jeanne, as a pitta client, responds best to questions that require her to verbalize her goals and obstacles, a practice which exercises her discernment muscle.-Otherwise, her routine to remain the same.

E. Results of recommendations: e-mail and telephone communications during Jeanne’s vacation visiting family and friends out-of-state:

June 27, 2008: e-mail from Jeanne“Just a note to say that I finally bought a neti pot and have used in twice without much difficulty. I noticed when I did my yoga today, my breathing was quieter”.

July 11, 2008:I called Jeanne in response to an e-mail where she suggested I call her during her drive to Long Island from Delaware. When I called, she sounded nervous and aggravated at traffic, so we agreed to speak again to re-schedule.

July 24, 2008: e-mail from Jeanne“Sorry to take so long getting back to you. Summer's good, but hectic. Also learned I may not have a job when school starts due to state of budget. I have been doing yoga, 4x weekly. Still usually very stiff and/or sore. Am making the car trip back later today or tomorrow morning. Either way, you can reach me on my cell tomorrow while I'm on the road.”

E. Results of recommendations: ninth session, July 29, 2008:-She still uses the neti pot, although not regularly. She even recommended it to a friend. -Jeanne uses the following words repeatedly: “scared, worried, anxious, guilty” in describing the emotional state she has been in all summer, including today. She was convinced she was out of a job until she finally called the school yesterday, only to find out she is still scheduled to teach according to plan. She was worried about her tenant and her mother, she was anxious about “having to avoid my brother”, she was scared about losing her job, she felt guilty about leaving her dogs. This highlights her need to balance vata.-For her trip, she drove 200 miles almost non-stop, as she only stopped briefly for gas. When she got out of the car, she found it hard to stand upright because of stiffness in her body. She knows this is the result of not taking breaks when driving, but when driving long distances, “I just want to get through it the quickest way possible”. Her left knee started to bother her since the car trip also. She does not recall whether this is the same knee she hurt during her car accident years ago. She admits that she doesn’t like to drive, and has noticed her body get tense when she does. On this trip, she made a conscious effort to try to relax her shoulders, release her grip and/or change her hand position on the steering wheel, etc. as she was driving. She felt the intensity of her back pain aggravate as she was driving. At this point, she remembered the pranayama for pain. She said: “I never got that before, about breathing into the hurt point”. Yet she found herself leaning forward into the steering wheel and breathing into the her back pain until it lessened. -Jeanne noticed an increase in the intensity of her pain (from a level 3 to a level 7) during her time away. She acknowledges that stress aggravates her pain, and described her stress factors as having to “pack, haul, drive, drag, caretake, worry, spend an hour looking for my dog, get stuck in two mile an hour traffic”. She also has no regular routine now. She has been feeling pain during certain everyday movements, such as sitting, getting up from sitting, sitting up from laying down, bending over. Assuming she can find a comfortable position, she finds a respite in stillness. She describes the pain as “a board without much flexibility”. She feels on

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and off discomfort in other parts of her body but is unaware as to whether there is a connection to her back. While she was talking about her pain, she was sitting with lumbar support and was not feeling it. She rose to her feet to point to the “hurt point”: a stripe across her low back as high as T12/L1 and as low as L3), and as wide as the distance between her left pelvic crest to the other, just above the crest of her pelvis. Jeanne clarified that it is only in the last year, since she started working as a schoolteacher, that certain movements, such as the ones mentioned above, as well as asanas (which she used to practice in a group setting) began to hurt. In this last year, she has felt a lot of pressure just to stay afloat, and felt the strain of having her classes monitored, of standing most of the day, and of meeting expectations, internal and external. I perceived a sense of tightness, compression even in her manner of describing the experience. Today she feels a level 3 pain, with movement only.-She did the practice 4 times a week during the month she was away. When I asked her insights on her practice, she said that she can’t tell whether the motions aggravate her pain or whether the motions will ultimately help the pain go away. I asked her to demonstrate some of the poses where she felt pain. In adho mukha svanasana, she was keeping her head up, which was causing her strain. When I asked her to do it with her knees bent, hips tilted up and head down, she said she felt no pain. She felt the pain in her back rolling down from the setubandhasana. We didn’t try Jathara Parivartanasana, because she said even coming in and out caused pain. She likes apanasana. She feels more comfortable doing paripurna navasana with her feet elevated, but doesn’t want to do it anymore. As for the JFS practice, she insists “it is boring” and is unmotivated to continue it. -I told her that I believed her pain was related to her emotions, specifically her stress. I explained how emotions create a response in the body, and vice versa. Since her breath is her tool to manage her emotions, I recommended pranayama as her main practice, to stabilize the pain. While she demonstrated her breathing, I noticed that her chest was expanding but her abdomen was not. It was as though the top of her body was disconnected from the bottom. She felt this as well. She thinks that because she gained weight over the summer (she voiced numerous negative comments about her appearance throughout the session), she is reluctant to expand her abdomen and make it “even bigger”. She also acknowledges that her breath is usually shallow and confined to her chest. I explained the “flight or fight” response and how it affects the body. -After practicing a few rounds of practicing sama vritti ujay and seeing movement in the abdominal region, I asked her to demonstrate the sunbird while breathing this way, so she could experience the difference between movements initiated by the breath versus movements initiated by the muscles. She suddenly stopped. She didn’t want to do the sunbird anymore, even with padding under the knees. This is the second time I notice she really dislikes doing the sunbird. I asked why, but she does not respond. All she said was, “I’m tired, I don’t want to do it anymore”. -Taking off from her positive experience with the pain pranayama in the car, I asked her to do a variation of paschimottanasana, with her knees bent enough to rest her chest on her thighs. She practiced sending her breath to her back on the inhale and releasing the pain on the exhale. She liked this a lot, noting how while in the car the pain only lessened, in doing this now her pain disappeared. She is eager to do this practice more than just once a day. This underscores the importance of creating a team effort with a pitta client for best results.

D. Recommendations after ninth session, July 29, 2008:

-Homework: targeted for her to learn how to manage her pain based upon what has worked for her in the past, as well as promote relaxation, which relieves her pain. 1. Lie down on back facing up. Six rounds of breathing (1 round = 1 inhale plus 1 exhale). During inhale, follow the breath down until reach the pelvic floor, or at least below the navel. During exhale follow the breath upwards, until it exits through the nose. Try to find a steady pace (sama vritti), slow and smooth.

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2. Apanasana: Hold for at least 3 rounds of breathing. Keep the breath steady, slow and smooth. 3. Paschimottanasana variation: knees bent a lot, feet together, flat on the floor, bending forward from the waist to rest the chest and abdomen on the thighs. Hands wrap around legs wherever they reach. Find a comfortable position. Inhale into hurt point in lower back, exhale visualize the pain becoming smaller. Keep going until the pain is gone.4. Transition from sitting to lying down: hugging with the knees to chest until back is on the mat. Once lying down on the mat, repeat step #1.5. Yoni Mudra above the navel. Inhale into the “hurt point”, and during exhale visualize the pain traveling to the space between the hands. Keep the breath steady, slow and smooth. Six rounds or until feel you feel a sensation between the hands.6. Visualize a place where previously have felt safe, serene and nurtured. Stay here as long as it feels appropriate. (Jeanne remarked it has been years since she has been in that place).7. Visualize a magnetic field around the body, attracting what is "put out there". Repeat mentally "I am patience" (she chose that mantra, as what she wanted the most to attract) 6 times, or until it feels done. As the mantra is repeated, she is visualize herself in a situation exercising patience. 8. Repeat step #2. - The goal is that in decreasing the tendency for restless breath, vata will be diminished, thereby

triggering relaxation of body and mind. Vata is released with gentleness, not rigidity. If she associates an experience of serenity with doing her homework, this could encourage a consistent practice. Also, learning how to apply the pain pranayamas in daily life empowers Jeanne to manage her own pain, irrespective of external circumstances, thereby stabilizing her condition. Finally, by having a practice that fosters relaxation of effort, pitta can also be stabilized. Vata and pitta imbalances must be addressed and managed before strengthening occurs (the kapha component of the program).

- The visualizations and mantra repetition have several purposes: (1) to help Jeanne recall a memory of a time when her needs were met and she felt safe (she couldn’t think of one today, saying “it’s been a long, long time”); (2) to stay in that place long enough to rest from her anxiety; (3) to attract positive thoughts and scenarios; (4) to stop energy leaks. In Chapter 2 sutra 34 of the Yoga Sutras, Patanjali states, in part: “negative thoughts and emotions are violent, in that they cause injury to yourself an others . . . Therefore, when you consistently cultivate the opposite thoughts and emotions, the unwholesome tendencies are gradually destroyed.” This also is a practice that cultivates discernment, as the practitioner experience positive habits assisting her own goals, which moves (rajas) pitta from a tamasic state (I know what I have to do but I don’t want to do it) to a sattwic state.

-Yoni mudra also assists in sealing energy leaks.

E. Results of recommendations: tenth session, August 8, 2008:

-Jeanne was excited to tell me the good news that she had 3 pain free days. She made a joke that the way out of pain was to “be a slug”. Those three days she rested and participated in enjoyable activities. The pain came back yesterday, predictably, she acknowledged, after carrying heavy items continuously, without taking breaks. She said, with a laugh, that she has a habit of procrastinating doing what she does not like to do, which results in having to get it done anyway but in a shorter period of time. This is the reason she rushes through certain activities. She explicitly stated that she places more importance on saving time than avoiding pain. This statement evinces her tamasic pitta imbalance. Using the yogic view of how thoughts and emotions affect the physical body as a backdrop, I recommended she make an inner inquiry (swadyaya) into what emotions or beliefs are driving the decisions to engage in actions that result in pain. This scenario demonstrates how attachment, which Patanjali defines as “the dwelling upon pleasure”, “and aversion, defined as “the dwelling upon pain” work cause suffering. Self study is the first step to identify the causes of suffering in an individual’s life,

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which is a vata balancing technique. If vata becomes balanced, then a choice to change habits (requiring tapas, or discipline) can be seen. -She was pain free today, no matter what she did. No matter if she stood, sit, walked still no pain. Even when she expected a movement to cause pain, it didn’t. She is in a celebratory mood today, looking forward to a dinner party she is hosting tomorrow night tomorrow night (to which she invited me). She smiled broadly as she described the dishes she is making and her love of cooking with fresh ingredients. She is also very happy about the school’s granting her request to teach 8th grade. -She did the practice the majority of the days, the full practice once per day, then the pain pranayamas separately when she felt pain. She experiences relief as a result of the pain pranayama practice. She is able to feel her breath expanding her lower back when she feels pain. -When she practiced visualizations, her said her mind traveled back to childhood summers spent visiting an aunt in New York, where she spent long periods floating face up on a pool, sounds muffled by the water on her ears, completely relaxed and worry-free. I congratulated her efforts in finding a memory that brings her physical and mental repose. She remembered how much she enjoys swimming and voiced an intention to schedule going to the pool after school a few days a week. I suggested she could end her swimming routine with savasana in the pool, practicing sama vritti ujay and noticing her body’s responses to it (sinking, floating?). She appeared to really like that idea. The purpose would be for her to distinguish between exertion and relaxation, and the effects of balancing one with the other.-In terms of savasana techniques, she says that what works best for her is to consciously follow the breath and stick with that only, because it frees her up from having to remember what’s next. I suggested she practice only one technique per savasana session until she became familiar with the different techniques. She appeared receptive to this.

D. Recommendations after tenth session, July 29, 2008:

-Seek help when needing to carry heavy objects. Discussed the possibility of having large/heavy items delivered instead of trying to do it all herself. She offered some suggestions on how she thought this could be done.

-Schedule breaks! She responded that she got a stool to she can take breaks from standing when she goes back to teaching.

-Practice pain managements techniques whenever necessary (breathe into the pain appears to be Jeanne’s favorite). Yoni mudra practice to seal energy leaks.

-Self-study practices: to cultivate awareness of emotional responses to external situations: 1. Gave her a copy of a cartoon strip entitled “Carrying a Woman Across A River” (see

Appendix) as an example of how an emotional load can get heavy without one’s conscious awareness of it. “This is good,” she said, chucking.

2. Jeanne’s negative emotional response to driving manifests physically in gripping the wheel, tensing the shoulders, etc. I suggested the book “Zen Driving,” and handed her a copy (see Appendix). This book contains techniques to practice detachment through cultivating acceptance while driving. This a practical way to drive through the point Patanjali makes in Chapter 1 sutras 7 and 8, where he describes attachment and aversion. Since Jeanne had a hard time practicing awareness in stillness or relaxation, a practical meditation, during a physical activity that she consciously associates with pain, might be more effective for her.

3. Practice slowing down the breath and practicing sama vritti ujay during stressful situations, even if no pain. Notice what happens. How do the body and the mind react to the breathing? Is there a change?

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-Self-discipline and purification: what to do with the awareness cultivated:

1. Gave her a copy of a cartoon strip entitled “The Weeping Lady” (see Appendix) as an example of how a person chose to change her perspective. She responded: “yes, the glass half-empty, half full approach”. This let me know she understood the concept.

2. Techniques from the Yoga Sutras:-contemplation on what it means to treat oneself “with great respect and love”. -to “cultivat[e] attitudes of friendliness towards happiness, compassion toward suffering, delight toward virtue, and equanimity toward vice.” (YS 1,33)-“Negative thoughts and emotions are violent, in that they cause injury to yourself and others, regardless of whether they are performed by you, done by others, or you permit them to be done. They arise from greed, anger or delusion regardless of whether they arise from mild, moderate, or excessive emotional intensity . . . Therefore, when you consistently cultivate the opposite thoughts and emotions, the unwholesome tendencies are gradually destroyed.” (YS 2, 34).After identifying examples of negative thoughts (“I am lazy, I have a huge ugly belly”) she asked: “if I always accept myself how will I ever improve anything?” She acknowledged the belief that acceptance always equated laziness or stagnation. I recommended that she put that belief to the test, by trying to improve something in her life through a positive, rather than negative approach, such as congratulating herself when taking steps that promoted her goals. The idea is to find a positive inspiration that will motivate change (such as “I feel so good when I eat healthy foods in balanced proportions, that I want to continue eating that way”). This really seemed to grab her attention. -Repeat affirmations: of thoughts want to cultivate - examples: “I release anything that does not serve me and ask it to release me.” “I trust that when something leaves my life, something better is coming” 3. Continue visualizations during savasana, pool savasana. Encouraged her to create other

visualizations that promoted relaxation and feelings of safety and well being, because in creating mental scenarios of serenity and happiness she is attracting that on a physical level as well.

- Devotion:

1. Gratitude practice: find one thing each day to be grateful for, and remind yourself throughout the day. Takes attention away from the usual mental spin and may restore perspective of what is important.

Summary:

Jeanne is a pitta client that needs to be heard. She is very intelligent and likes to understand as well as challenge as part of her process. She responds well to humor, and respects directness and conviction. Our relationship has both comfort and friction. Jeanne feels comfortable to establish an easy rapport and to share her perceptions. Yet there is friction (resistance) anytime her lifestyle habits are challenged. The best approach is to create a team effort to build a practice. Because Jeanne’s main vikruti is vata (more on that on Section III), that practice needs to focus on gentleness rather than rigidity. This is challenging for Jeanne.

Jeanne has learned through this program to manage her pain. However, Jeanne’s main hurdle is that she lacks a strong sankalpa (intention) to end it. Jeanne admits that she places more importance on saving time than avoiding pain. Between the two priorities, she never chooses to be free of pain, even when she believes that pain is avoidable by modifying or eliminating her performance of a task.

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The other hurdle is that Jeanne’s is not fully conscious about the degree her emotional responses to stressful scenarios create pain. While on our initial intake it appeared that Jeanne’s back pain began after her two car accidents nearly 20 years ago, she revealed towards the end that the pain did not interfere everyday activities (such as sitting and standing) or arise when practicing yoga asanas until one year ago. In the last year, she describes feeling internal and external pressure to succeed in a very difficult environment over which she had little control and felt minimal support from the administration. Jeanne describes herself as a perfectionist, and describes habits exemplifying a tendency to keep going (stand, sit, squat, drive, unpack, work, caretake) for long periods without taking breaks. Moreover, she constantly expresses worry that she will lose this job, which is her main source of income. It naturally follows that Jeanne’s pain was exacerbated over the summer. She related in detail how much time she spent watching school board budget hearings, in anticipation of budget cuts that might affect her job. Even after she received a letter saying her job had been “surplused” (which meant she would keep her job but get re-assigned to a new school) she procrastinated making the follow-up call for confirmation and re-assignment, only to learn, when she finally made the call, that her job at the old school was intact. In addition, she drove long distances without stopping, and Jeanne does not like to drive: she describes how her body tenses automatically. Finally, during most of her time away she was taking care of her mother and avoiding contact with her brother (“which wasn’t easy,” she said, “because he was there all the time”. I don’t believe the pain is structural, that is, the result of injury. While Jeanne acknowledges that stress affects her back pain, she believes that cause of her pain is structural. For this reason, I recommended awareness exercises (meditation) during stressful activities such as driving, so she can reach her own conclusions based upon her observations.

In light of the above, Jeanne’s focus needs to be relaxation rather than building muscular strength, at least until she is free of pain. In releasing emotional responses and replenishing prana where depleted, the pain has an opportunity to subside (see also Section III). It is also important to practice yoni mudra, to seal energetic leaks. Gentle vata reducing vinyassas, such as the palm tree vinyassa (refer to Ayurvedic Yoga Therapy book), would also be advisable, but I did not recommend this as I have not yet received blessings to teach this practice.

II. LOW BACK PAIN

A. Description: Pain that affects the back below the ribs and above the legs, in the lumbar spine or sacroilliac joint area. As the connection between the upper and lower body, the lower back bears most of the body’s weight, which makes it easy to injure during the acts of lifting, reaching and twisting. “Pain can occur when, for example, someone lifts something too heavy or overstretches, causing a sprain, strain, or spasm in one of the muscles or ligaments in the back.” (National Institute of Neurological Disorders and Stroke www.ninds.nih.gov).

Tension Myositis Syndrome (TMS): a pain disorder resulting from a physiological response to a certain common emotional situations. “Statistically, the low back-buttock area is the most common location for TMS”. (Sarno, John, M.D., Healing Back Pain, New York: Warner Books 1991, at page 6). For individuals suffering from TMS, physical events act as triggers rather than the cause of the pain, since certain emotional states result in mild oxygen deprivation of certain muscles, tendons and ligaments. Thus, the staring point of recovery occurs when a person becomes aware of the emotional circumstances surrounding the onset of an acute attack (Id., pages 12,13, 68). Dr. Sarno defines stress as “any factor, influence or condition that tests, strains or in any way puts pressure on individuals. . . Stress can be either external or internal to the individual. Examples of external stress are your job, financial problems, illness, change of job or home, caring for children or parents. However, the internal stressors appear to be more important in the production of tension. These are one’s own personal attributes, like

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conscientiousness, perfectionism, the need to excel, and so forth.” (Id., pages 30-31). “[T]he need to accomplish or live up to some ideal role, such as being the best parent, student, or worker, is very common in people who get TMS.” (Id., page 35). Dr. Sarno postulates that individuals with such personality traits would naturally be anxious as to how situations would unfold, and that anything that is unconsciously causing anxiety will tend to cause anger as well when things don’t go according to plan (Id., pages 37, 39). In his view, the physical pain serves to distract attention from undesirable emotions.

B. Gross symptoms and subtle physical sensations:

Gross: Anandamaya kosha: “Symptoms may range from muscle ache to shooting or stabbing pain, limited flexibility and/or range of motion, or an inability to stand straight. Occasionally, pain felt in one part of the body may “radiate” from a disorder or injury elsewhere in the body”. (National Institute of Neurological Disorders and Stroke www.ninds.nih.gov). Subtle: Pranamaya kosha: When thoracic curvatures exist, intercostal breathing may be affected. In all cases, rajasic or tamasic thoughts and emotions impair the smooth flow of the breath, resulting in loss and de-stabilization of prana. Low energy.Manomana kosha: sleep may be impaired because of increasing rapid thoughts of worry. The mind’s attention could become focused on fear of pain and loss of activities. There is a loss of discernment. Negativity, anger. Jnanamaya kosha: because of the vata imbalance, the mind feels unsafe, unable to surrender to the unknown and unknowable. In the absence of silence, the voice of one’s own wisdom is inaudible. Lack of trust in the Divine order.Anandamaya kosha: Loss of natural state of enjoyment.

C. Related challenges

When a person is not consciously aware of habitual behaviors that cause them pain, or when an individual’s attachment to certain activities outweighs their desire to be free of pain, they will make choices that impair their quality of life.

Moreover, the fear of getting the pain back creates a mood of anticipation present even during a practice which could help the condition. “Negative thoughts and emotions are violent,” Patanjali states in Chapter 2, sutra 34 of the Yoga Sutras (hereinafter “Y.S.”), “in that they cause injury to yourself and others”. The body materializes what the mind believes. Repetition of violent thoughts and/or actions (vata) eventually lead to inflammation (pitta) and solidification of habit and effect on body (kapha), causing stagnation, which makes change by way of “opposite thoughts and emotions” (Y.S. II, 34) difficult, and only achieved by “consistent earnest practice” (Y.S. I, 12). Constant practice of relaxation and meditation creates awareness of behavior, which balances vata. Replacing negative thoughts with positive ones balances pitta. Heart opening, forgiveness and compassion, maintenance, balances kapha.

III. AYURVEDIC ASSESSMENT AND RECOMMENDATIONS

Assessment: I suspect Jeanne has imbalances (vikruti) on all doshas based on the following factors:

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Vata Pitta Kapha

stress, anxiety, worry;lower back pain;irregularity (of physical triggers to pain, and intensity);low sensitivity to muscle actions; lacking full awareness of recurring emotions.

anger;perfectionism; criticism of others; desire to control outcomes;reluctant to minimize activities that she knows trigger pain(tamasic pitta);busy, never enough time.

weakness, cramping;localized pain;attachment to the past

From an ayurvedic perspective, the imbalances in vata, pitta and kapha qualities should be addressed in that order. The progression of the development of pain follows that order as well, as a vata imbalance (resulting from repetition of stressful habits) eventually causes inflammation (indicative of a pitta imbalance) and the pitta imbalance eventually becomes a kapha imbalance (manifesting as weakness and/or stagnation). Once awareness of the gross and subtle causes of pain arises through self study, and a new repetitive course of conduct for the purpose of promoting relaxation and awareness is consistently and earnestly pursued, vata is reduced. Once there is relaxation, there can be a reduction of effort, which lowers pitta, allowing for clarity of thought and discernment to surface. Once vata and pitta are addressed, then there can be a significant or a long term shift in habits. Stress and inflammation, once managed, no longer create an impediment for strengthening, whether muscular or pertaining to the body’s ability to heal itself.

Notwithstanding the above, it is important to have a focus for the program based upon which dosha appears most out of balance. In Jeanne’s case, her vata imbalance, manifesting as constant foreboding about future events, is tied to pitta imbalance, evinced by her constant irritation over her inability, despite her best efforts, to control the effects of the actions of others over her best laid plans. Since the anxiety appears to be the source of anger, the focus of Jeanne’s program needs to be relaxation, pranayama and meditation. It is also imperative that Jeanne learn to identify and discriminate the emotional sources of her pain.

IV. COMMON BODY READING

-Carrying angle - signals tight shoulder external rotators and weak shoulder adductors.-Tilted head to the right - signals tight SCM and upper trapezius on left; weak SCM and upper trapezius on right.-Forward head-tight SCM and weak upper trapezius.-Feet turned out, especially on right side - tight psoas, external hip rotators and gluteus maximum; weak TFL, gluteus minumus.-Flat back- tight middle trapezius, abdominis rectus; weak hip flexors, psoas, lumbar erectors.

V. ACTIVITIES TO MODIFY

-Create a habit to take breaks: from standing, from working, from sitting, from driving.

-Seek assistance whenever there is a need to carry, lift, reach for heavy objects.

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VI. GENERAL RECOMMENDATIONS FOR CONDITION

A. THERAPEUTIC/FREE OF PAIN:

According to Dr. John Sarno, author of Healing Back Pain, there are two elements for treatment:

1. “The acquisition of knowledge, of insight into the nature of the disorder.2. The ability to act on that knowledge and thereby change the brain’s behavior.”

From the yogic perspective, it all starts with a strong sankalpa (intention) to end pain. An effective practice is one where a person is empowered with the experience of relief as a result of their own efforts.

The following are effective means for pain management consistent with the yogic perspective:1. Pranayamas for pain: inhaling into pain, releasing it on the exhale; yoni mudra; breathing

below navel.2. Sama vritti ujay: promotes relaxation, increases breathing capacity.3. Postures: -Sacroiliac Stabilizing Exercise (if joint is imbalanced).-Joint Freeing Series - practiced in a gentle way.-Apanasana: can relieve tightness, discomfort, especially accompanied by deep breathing.-Savasana: relaxation relieves tightness in body, visualization promotes images of well being.4. Vinyassas: palm tree.

B. STABILIZE SITUATION AND LIFESTYLE RECOMMENDATIONS:1. Become aware of emotional states surrounding activities associated with triggering/

aggravating pain. This is the search of the individual for the truth of the condition. In yoga this is known as self study, or swadyaya.

2. Mantra meditation/chanting: mantra purifies as well as protects the mind from negative thoughts and emotions which cause injury. In yoga this is known as self-discipline and purification, or tapas. This practice can also be devotional in nature.

3. “By cultivating attitudes of friendliness towards happiness, compassion toward suffering, delight toward virtue, and equanimity towards vice, thoughts become purified, and the obstacles to self-knowledge are lessened.” (Y.S. 1,33).

4. Initiate a habit of decreasing the intensity of effort expended on a particular project, including but not limited to taking frequent breaks, in search of a state of steadiness and comfort, as outlined in chapter 2 sutra 46 of Patanjali’s Yoga Sutras.

5. Cultivate a practice of gratitude. This builds devotion to a higher sense of Self. 6. Regular schedule: meals, wake up, sleep.

C. MAINTENANCE: 1. Consistent earnest practice over a long period of time of the above mentioned.2. Yoga Nidra - to cultivate awareness of the effects of the emotions on the mind and the body,

and to enhance experience of witness identity. 3. Exercises from the Isolation Series (Chapter 17 Structural Yoga Therapy Book), in

preparation for asana, especially: Groin Stretch, Pelvic Tilt and Thrust, Rolling Setubandhasana.

4. Asanas: practiced dynamically, coordinated with smooth ujay breath, seeking steadiness and comfort:

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To strengthen hip flexors: Weak hip flexors can cause flat back (loss of natural curves, such as lumbar curve), making the back more vulnerable to strain:

-psoas/saritorius isolation: (sitting in dandasana, lift foot 1 inch off the ground and out to the side, externally rotate the hip, then touch opposite knee with toes).-Uttanasana (also stretches hamstrings, which relieves strain on back)-Adho mukha svanasana-Urdhva prasarita padasana -Apanasana (tiling the pelvis up and down)-Dandasana -Paripurna navasana (also strengthens the rectus abdominis, which stabilizes the back)-Baddha konasana

To strengthen hip extensors:

-Virabhadrasana 1 (back leg)-Virabhadrasana 2 (strength in gluteus assists sacroiliac joint stability, also stretch of adductors releases lower back compression) -Salabhasana (note: this pose must be modified for those with spinal curvatures)

VII. QUESTIONS AND ANSWERS FROM YOGAFORUMS.COM

April 2005 Post Subject: Stress, effects on all 5 koshas

Q-Mukunda,In the years you have been working with clients, how have you seen stress redefine itself in our society? In addition to the Annamaya, Pranamaya and Manomaya koshas, has stress spread to encompass Vijnanamaya and Anandamaya as well? Or has it always been affecting all 5?

If it has been affecting all five, where do you believe stress manifests itself first?

with great respect and love,Fawn[

A-MukundaFor those unfamiliar with the concept of our multidimensional anatomy, the koshas, refer to Structural Yoga Therapy, chapter 6.

Stress has not changed. The ways in which we respond to it have changed. There are many studies on the changing of epidemics, heart disease, cancer, and more recently environmental toxicity. When one looks at ancient medical texts death came much earlier and often due to traumas from wars and the malnutrition brought on by loss of crops during wartime.The two sutlest koshas vijnana and ananda are indicators of spiritual stress, not being connected to wisdom and higher power. Much of our wisdom has needed to survive the test of time thus we seek wisdom from those texts that are highly revered for thousands of years. That which is available as contemporary insights would rarely survive such a test. We need the help of a thorough investigation into this human condition and what has been of help in the past. By seeking historical ways of dealing with stress we can see how wise people of our era have adapted these teachings for this modern life.

In looking at Classical Yoga of the Yoga Sutras II, 4 we see that Patanjali viewed all stress as originating from avidya, ignorance which is the fourth kosha. When we disidentify ourself to be merely our physical body we tend to not listen to messages that come from a subtler level. Then

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there are others who are more "in their heads" who do not listen to messages coming from a grosser kosha. So it depends on where you conceive yourself to live that is the source of your perspective of stress. namaste

June 6, 2005 Post subject: lumbar pain

Q- Hi,I attended one of your workshops recently and you gave us an exercise to loosen up the lumbar area. I have chronic lumbar pain from a yoga pose I did wrong a couple of years ago. I have your joint-freeing CD and use it, but the pose you showed us isn't on it...and as I recall, it was a bit harder, with the leg (or legs?) extended. Can you help me recall how to do it? Thanks!Namaste, Susan A- I suspect what you are asking for is the sacroiliac mobilization exercise done by sitting in Z pose with the feet placed to the side. One foot adjacent to inner knee other foot beside outer pelvis. First part is to rock the pelvic back and forth 12X then lift the hip of the foot outside it and turn the thigh into internal rotation so your torso will twist. Move in and out of both motions 12X until your body releases hip or lumbar pain due to improper motion of sacroiliac. More details in person or from any of my students, graduates are listed on my website. www.yogatherapycenter.org namaste mukunda

VIII. REFERENCES - FOR FURTHER INFORMATION

Sarno, John, M.D., Healing Back Pain, New York, NY: Warner Books 1991.

Stiles, Mukunda, Ayurvedic Yoga Therapy, Twin Lakes, WI: Lotus Press 2007.

Stiles, Mukunda. Structural Yoga Therapy, Boston, MA: Samuel Weiser, 2005.

Stiles, Mukunda, Yoga Sutras of Patanjali, San Francisco, CA: Samuel Weiser, 2002.

http://www.ninds.nih.gov

www.iytyogatherapy.com click on Yoga Therapy Journal for articles on- stress management- low back pain

IX. APPENDIX

Berger, K.T., Zen Driving, New York: Ballantine Books 1988.“Carrying a Woman Across a River”, and “The Weeping Lady”, from: Bruya, Brian and Chung, Tsai Chih, Zen Stories: The Staff and Shout of the Venerable Ones.

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X. BIOGRAPHY

Annabelle received a Bachelor of Arts in English and a Juris Doctor degree from Boston College. She has been practicing yoga for the past nine years. She was first trained in the Sivananda lineage of yoga. Inspired by Krishnamacharya’s concept of yoga tailored to the individual, she soon found herself drawn to Mukunda Stiles, who has been guiding her studies and teaching during the past year.

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